Go to the Federal Communications Commission homepage at www.fcc.gov

FCC Form 399: Incentive Auction Relocation Reimbursement Fund System

Approved by OMB 3060-1178
Go to the Federal Communications Commission homepage at www.fcc.gov

(REFERENCE COPY - Not for submission)FCC Form 399: Incentive Auction Relocation Reimbursement Fund System

File Number:
0000028481
FRN:
0004573473
Facility ID:
17611
Repack Channel:
24 (UHF)
Entity:
Broadcaster
Filing Status:
Submitted
Date Submitted:
09/14/2017

Applicant Information

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Applicant Name, Type, and Contact Information

Applicant Address Phone Email Applicant Type

THE DISTRICT BOARD OF TRUSTEES, PENSACOLA STATE COLLEGE, FL.

Doing Business As: THE DISTRICT BOARD OF TRUSTEES, PENSACOLA STATE COLLEGE, FL.

Darrel Harrison

1000 COLLEGE BLVD

PENSACOLA, FL 32504

United States

+1 (850) 484-1285 dharrison@wsre.org Government Entity

Reimbursement Contact Information

Reimbursement Contact Name and Information

Applicant Address Phone Email

[Confidential]

 

 

 


Preparer Contact Information

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Preparer Contact Name and Information

Applicant Address Phone Email

William T Godfrey , Jr. .

Consulting Engineers

Kessler and Gehman Associates, Inc.

William T. Godfrey, Jr.

Kessler and Gehman Associates, Inc.

507 NW 60 Street, Suite D

Gainesville, FL 32607

United States

+1 (352) 332-3157 bill@kesslerandgehman.com

Broadcaster Information and Transition Plan

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Question Response
Will the station be sharing equipment with another broadcast television station or stations (e.g., a shared antenna, co-location on a tower, use of the same transmitter room, multiple transmitters feeding a combiner, etc.)? If yes, enter the facility ID's of the other stations and click 'prefill' to download those stations' licensing information. Yes
Briefly describe transition plan Replace transmitter and antenna. Purchase new interim antenna and transmission line for continued operation during construction and duration of the assigned phase. Map and analyze tower; design and implement modifications if required. See attached.

Transmitters

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Section Question Response
Transmitter Related Expenses Do you have transmitter related expenses? Yes

Primary Transmitter

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Existing Transmitter Information

Section Question Response
Existing Transmitter Description Type of change Purchase New
Use Primary (Main)
Description of Use  
Ownership Owned
Owner  
Site  
Is this transmitter currently shared with another station? No
Is this transmitter currently in operating condition? Yes
Existing Transmitter Manufacturer and Type Manufacturer
Model Diamond
Year 2001
Type Solid state
IOT Power Type  
Description  
Power capacity  
Solid State Cooling Air
Solid State Power Capacity 20.1 kw
Other Transmitter Type  

Primary Transmitter

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New Transmitter Costs

Section Question Response
New Transmitter Use Primary (Main)
Description of Use  
Change Type Purchase New
Is this a request for upgraded equipment? Yes
Manufacturer
Model TBD
Transmitter Type Solid state
IOT Power Type  
Other  
Power capacity  
Solid State Cooling Liquid
Solid State Power Capacity 23.3 kw
Other Transmitter Type  
Justification for New Transmitter The manufacturer of the existing transmitter advises that the transmitter cannot be re-tuned to the assigned channel. New air cooled transmitters are not available at this power level. See attachment.

Primary Transmitter

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Other Transmitter Costs

Section Question Response
Electrical Service Service Entrance (3 phases 800A 208V) Yes
Switchgear (industrial 800 amp) Yes
Transformer (480V) Yes
Power 150 kVA
Rigid Conduit and Wiring Yes
Size 3 inches
Length 100.0 feet
Other Electrical Service No
Description  
HVAC Service Does the replacement transmitter require HVAC Service? Yes
Type Cooling Only
Size 5 tons
Other Size  
Transmitter Building Addition/Modification or Leasehold Improvement Does the Transmitter Building require an addition, modification, other leashold improvement? No
Size
Channel 14 Costs Is an RF Consulting Engineer needed?
Is a channel 14 Mask Filer needed?
Is additional field engineering time needed?
Number of Days  

Primary Transmitter

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Other Transmitter Cost Not Listed

Name Description

Standby Exciter and Switch

Standby Exciter with Automatic Change Over Switch

Additional Interior RF System

Interior RF System Existing Transmitter to Interim Transmission line

Antennas

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Section Question Response
Antenna Related Expenses Do you have antenna related expenses? Yes

Primary Antenna

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Existing Antenna Information

Section Question Response
Existing Antenna Description Type of change Purchase New
Antenna Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing antenna shared with another station or stations? No
Is the existing antenna directional? Yes
Is antenna in operating condition? Yes
Is antenna located on or in close proximity to an antenna farm? No
Existing Antenna Manufacturer and Type Class Full Power
Mounting Top-mount single
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted coaxial
Number of Stations Supported N/A
Number of Panels N/A
Design power capacity in use N/A
Lower Limit N/A
Upper Limit N/A
Other Antenna Type N/A
ERP: 1000.00 kW
Manufacturer
Model ATW-22H4-HTC5-31H
Year 2007

Primary Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Primary (Main)
Description of Use N/A
Change Type Purchase New
Is this a request for upgraded equipment? No
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Type Class Full Power
Mounting Top-mount single
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted coaxial
Number of Stations Supported N/A
Number of Panels/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 859.00 kW
Manufacturer
Model ATW17H3-HTC5-24H
Year 2018
Justification for New Antenna The existing primary antenna is a single channel slotted coaxial which cannot accommodate the assigned channel.

Primary Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? No
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? N/A
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 8 3/16 inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? No
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? No
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Primary Antenna

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Other Antenna Cost Not Listed

Information not provided.

Interim Antenna

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New Antenna Costs

Section Question Response
New Antenna Description Use Interim
Description of Use N/A
Change Type Purchase New
Ownership Owned
Owner N/A
Is antenna shared? No
Is antenna directional? Yes
Will antenna be located on or in close proximity to an antenna farm? No
New Antenna Manufacturer and Type Class Full Power
Mounting Side-mount
Antenna position in stack Not in Stack
Polarization Horizontal
Type Slotted coaxial
Number of Stations Supported N/A
Number of Panels/Bays N/A
Lower Limit N/A
Upper Limit N/A
Design power capacity in use N/A
Other Antenna Type N/A
ERP: 1000.00 kW
Manufacturer
Model TBD
Year 2018
Justification for New Antenna An interim antenna is necessary to keep station on the air during primary antenna replacement and for the duration of the assigned phase.

Interim Antenna

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Other Antenna Costs

Section Question Response
Combiner for Shared Antenna Do you need a Combiner for a Shared Antenna? No
Type
Number of channels supported N/A
Frequencies of channels supported N/A
Frequency N/A
Do you need a combiner output splitter/switcher for dual feed lines? N/A
Elbow Complex Do you require the separate purchase of the Elbow Complex? Yes
Broadband or Single Channel? Single Channel
Feed Line Size 8 3/16 inches
Side Mount Brackets Do you require the separate purchase of side mount brackets for a high power antenna? Yes
Pattern Scatter Analysis Do you require separate purchase of pattern scatter analysis for a side mount high or medium power antenna? Yes
Sweep Test Do you require the sweep testing of transmission line and antenna? Yes

Interim Antenna

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Other Antenna Cost Not Listed

Information not provided.

Transmission Line

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Section Question Response
Transmission Line Related Expenses Do you have transmission line related expenses? Yes

Primary Transmission Line

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Existing Transmission Line

Section Question Response
Existing Transmission Line Description Type of change Utilize Existing
Use Primary (Main)
Description of Use N/A
Ownership Owned
Owner N/A
Site N/A
Is the existing transmission line shared with another station or stations? No
Is Transmission Line in operating condition? Yes
Existing Transmission Line Manufacturer and Type Manufacturer Andrew
Type Rigid
Diameter 8 3/16 inches
Segment Length 20'
Other Segment Length
Number of parallel runs 1
Length 2150 feet per run

Primary Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Sweep Tests

Sweep tests to establish performance of line on assigned channel.

Interim Transmission Line

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New Transmission Line

Section Question Response
New Transmission Line Costs Use Interim
Description of Use N/A
Change Type Purchase New
Type Rigid
Diameter 8 3/16 inches
Segment Length 20'
Other Segment Length
Number of parallel runs 1
Length 2000 feet per run
Justification for New Transmission Line An interim transmission line is necessary for the interim antenna to keep station on the air during primary antenna replacement and for the duration of the assigned phase. Interim antenna will be mounted 150 ft below 2000 ft AGL candelabra.

Interim Transmission Line

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Other Transmission Line Expenses Not Listed

Name Description

Sweep Test

Required for proof

Tower Equipment And Rigging Costs

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Section Question Response
Tower Equipment or Rigging Costs Changes Do you have tower equipment or rigging costs changes? Yes

Primary Tower

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Existing Tower

Section Question Response
Existing Tower Description Type of change Modify Existing
Tower Use Primary (Main)
Description of Use N/A
Ownership Leased
Is this tower consider Complex? Candelabra
Is this tower currently shared with any other stations? Yes
One or more FM, AM or TV radio broadcaster(s) Yes
Others Types of Users Yes
Is tower documented for structural analysis? No
Is tower compliant with Rev G? No
Existing Tower Structure Registration Do you have a tower registration number? Yes
ASR Number 1064671
Coordinates (NAD83) Latitude (NAD83) 30° 36' 41.0" N-
Longitude (NAD83) 087° 36' 26.4" W-
Overall Structure Height 1894.01 feet
Support Structure Height 1804.44 feet
Ground Elevation Above Mean Sea Level (AMSL) 105.97 feet
Structure Type GTOWER - Guyed Structure Used for Communication Purposes
Tower Owner SpectraSite Communications, LLC. through American Towers, LLC.
Date Constructed 04/06/2001

FM, AM or TV radio broadcasters. Facility ID's, Call Signs and Services of other broadcast stations with whom the tower is shared

Facility ID Call Sign Service
83740 WDPM-DT DTV
60827 WMPV-TV DTV
61243 WTKX-FM FM
73256 WMEZ FM
11906 WPMI-TV DTV
63431 WHFX FM
32946 WXBM-FM FM

Other Types of Users

Users
6 mwave license

Primary Tower

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Tower Modification Costs

Section Question Response
Engineering Study Please what type of engineering study is required, if any: Study needed for undocumented/poorly documented tower
Tower Reinforcements Please select whether tower reinforcements are needed: Major Reinforcements needed

Primary Tower

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Tower Rigging Costs

Section Question Response
Tower Rigging Costs Complex Tower Candelabra
Helicopter Services Required Are helicopter services required? No

Primary Tower

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Other Tower Expenses Not Listed

Information not provided.

Outside Professional Services Costs

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Section Question Response
Outside Project Management Services Do you require outside project management services? Yes
Number of Hours 1000
Explanation To schedule and coordinate multiple vendors, complete progress reports, and update Schedule 399. Station does not have available personnel or personnel trained in project management for such complex projects. Includes 95 hours for American Tower.
Outside RF consulting Engineering Services Perform engineering study for new channel assignment and antenna development Yes
Prepare engineering section of Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare engineering section of Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
Do you have Distributed Transmission System engineering services? N/A
Critical Facility N/A
Terrain-Shielded Facility N/A
Attorney and Other Outside Consulting Services Prepare and file Form FCC Construction Permit Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare and file Form FCC License to Cover Application Yes
For Auxiliary Facility No
For Main Facility Yes
Prepare request for Special Temporary Authority Yes
Quantity 1
NEPA Section 106 environmental review No
Environmental Assessment No
ASR Modification Yes
FAA Consultation (including preparation of FAA Form 7460) Yes
Negotiation of Lease and other Matter for Shared Locations Yes
Prepare or Review FCC Form 399 for Reimbursement Yes
Address transition timing and coordination issues w/ other stations and wireless providers Yes
RF Field Engineering Services Comprehensive coverage verification via field study Yes
RF exposure measurements Yes
Additional Field Engineering Service Yes
Number of Days 30
Justification It will be necessary to survey the site, plan the equipment, develop specifications for purchasing, and oversee multiple vendor RF projects. Station does not have available personnel or personnel trained in such services.

Outside Professional Services Costs

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Other Professional Services Expenses Not Listed

Information not provided.

Other Expenses

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Section Question Response
AM Pattern Disturbance Is an Impact Study needed? No
Is Remediation needed? No
Facility Expenses Name N/A
Other Distributed Transmission System Expenses Not listed N/A
Name N/A
Is Notification of a Medical Facility required as a result of DTV broadcasting? Yes
Permit and Filing Costs Local Zoning Yes
Non-zoning permits Yes
BLM or NFS Coordination No
FCC Construction Permit Minor Change No
FCC License to Cover Application No
FCC Special Temporary Authority Application No
Other Miscellaneous Expenses Does this relocation require paying Disposal Costs (for equipment and other waste, net of any salvage value)? Yes
Does this relocation require Equipment Delivery or Handling Charges not otherwise included in individual item costs? Yes
Does this relocation require Equipment Storage? Yes
Does this relocation require the Development and Airing of an Announcement regarding an upcoming channel change? Yes
Does this relocation require MVPD Notification of a Channel Change? Yes

Other Expenses

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Other Expenses Not Listed

Name Description

Additional Legal Fees

Additional legal fees due to coordinating multiple site user repack for University station.

Required Progress Reports

FCC required progress reports

Cost Information

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Transmitters

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $1,187,800.00 $1,163,450.00 N/A $0.00 N/A
Total for all systems $3,756,905.00 $3,835,650.00 N/A $0.00 N/A
Primary Transmitter TBD $1,187,800.00 $1,163,450.00 $0.00
Additional Interior RF System $140,000.00 $140,000.00 N/A N/A N/A
Standby Exciter and Switch $25,000.00 $25,000.00 N/A N/A N/A
Transformer 3 phase/480v - 150 KVA $24,900.00 $24,300.00 N/A N/A N/A
Switchgear - industrial 800 amp $37,150.00 $36,300.00 N/A N/A N/A
UHF - Liquid Cooled Solid State Transmitter 21 - 31 kW $922,000.00 $900,000.00 N/A N/A N/A
Service entrance 3 phase/800 amp/208 volt $14,050.00 $13,700.00 N/A N/A N/A
3" Rigid Conduit and Wiring (Cost per foot) $5,000.00 $4,900.00 N/A N/A N/A
5 Ton system $19,700.00 $19,250.00 There is insufficient space in the transmitter room for a new transmitter. We propose to build a new transmission facility in vacant space next door. Air conditioning will be required to offset the heat generated by the liquid cooled transmitter. N/A N/A

Components

Information not provided.

Cost Information

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Antennas

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $545,970.00 $683,800.00 N/A $0.00 N/A
Total for all systems $3,756,905.00 $3,835,650.00 N/A $0.00 N/A
Interim Antenna TBD $284,070.00 $282,900.00 $0.00
UHF - High Power, Side Mount, basic slot antenna, 1000 kW input, directional,, horizontally polarized $235,000.00 $235,000.00 N/A N/A N/A
Pattern scatter analysis for side mount high/med power antennas (if not included in antenna base cost) $5,120.00 $5,000.00 N/A N/A N/A
Side mount brackets for high power antennas (if not included in antenna base cost) $22,550.00 $22,000.00 N/A N/A N/A
Elbow complex, single channel, at antenna input, per 8 3/16. feedline (if needed) $14,850.00 $14,500.00 N/A N/A N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A N/A N/A
Primary Antenna ATW17H3-HTC5-24H $261,900.00 $400,900.00 $0.00
UHF - High Power Top Mount (200-1000 kW), One station antenna, horizontally polarized $240,500.00 $235,000.00 N/A N/A N/A
Sweep test of existing antenna $6,550.00 $6,400.00 N/A N/A N/A
Elbow complex, single channel, at antenna input, per 8 3/16. feedline (if needed) $14,850.00 $159,500.00 See attached sweep reports. The main transmission line is approximately 2,200 ft in length and has 11 tunes elbows for Channel 31 that must be replaced for Channel 24. N/A N/A

Components

Information not provided.

Cost Information

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Transmission Line

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $688,800.00 $672,800.00 N/A $0.00 N/A
Total for all systems $3,756,905.00 $3,835,650.00 N/A $0.00 N/A
Interim Transmission Line $682,400.00 $666,400.00 $0.00
Rigid Transmission Line - copper, 8 3/16" $676,000.00 $660,000.00 Required for interim operation to remain on the air during build-out and throughout phase to avoid significant coverage losses. Note: Testing and build-out period is in hurricane season and interim operation at full power is critical. N/A N/A
Sweep Test $6,400.00 $6,400.00 N/A N/A N/A
Primary Transmission Line $6,400.00 $6,400.00 $0.00
Sweep Tests $6,400.00 $6,400.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Tower Equipment and Rigging Costs

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $844,600.00 $812,400.00 N/A $0.00 N/A
Total for all systems $3,756,905.00 $3,835,650.00 N/A $0.00 N/A
Primary Tower GTOWER $844,600.00 $812,400.00 $0.00
Major tower reinforcement/modifications $409,500.00 $400,000.00 WSRE is the only Phase 7 station on the tower being repacked. Therefore, no costs can be shared for rigging. It is expected that the additional loads will cause the tower to fail. The structural failure is expected to be in the "Major" category. N/A N/A
Tower mapping for an undocumented/poorly documented tower and preparation of documentation necessary for tower load study $25,600.00 $12,400.00 Based on American Tower expenses spreadsheet N/A N/A
Complex Tower (includes, for example, those with candelabras and/or stacked antennas) $409,500.00 $400,000.00 This is a complex candelabra tower. N/A N/A

Components

Information not provided.

Cost Information

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Outside Professional Services

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $354,035.00 $367,750.00 N/A $0.00 N/A
Total for all systems $3,756,905.00 $3,835,650.00 N/A $0.00 N/A
Outside Professional Services $354,035.00 $367,750.00 $0.00
RF Exposure Measurements $20,500.00 $20,000.00 N/A N/A N/A
Comprehensive coverage verification via field study, if needed $81,900.00 $80,000.00 N/A N/A N/A
FAA consultant, including cost of preparing FAA Form 7460 (Notice of Proposed Construction), if needed for height increase $2,050.00 $2,000.00 N/A N/A N/A
ASR modification (prepare FCC Form 854) $2,050.00 $2,000.00 N/A N/A N/A
Attorney Fees - Prepare and File request for Special Temporary Authorization $3,585.00 $3,500.00 N/A N/A N/A
Attorney Fees - Negotiation of lease and other matters for shared locations $4,095.00 $25,000.00 The station's legal representative recommends $25,000 to cover this effort. N/A N/A
Attorney Fees -Prepare and File FCC Form 2100 (main), License to Cover Application $2,305.00 $2,250.00 N/A N/A N/A
Prepare request for Special Temporary Authorization $1,535.00 $1,500.00 N/A N/A N/A
Prepare and or review reimbursement form $2,560.00 $2,500.00 N/A N/A N/A
Project management of the transition $154,000.00 $150,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), Construction Permit Application $3,070.00 $3,000.00 N/A N/A N/A
Address transition timing and coordination issues w/ other stations and wireless $2,560.00 $2,500.00 N/A N/A N/A
Perform engineering study for new channel assignment and antenna development $7,170.00 $7,000.00 N/A N/A N/A
Prepare engineering section of FCC Form 2100 (main), License to Cover Application $1,535.00 $1,500.00 N/A N/A N/A
Attorney Fees - Prepare and File FCC Form 2100 (main), Construction Permit Application $5,120.00 $5,000.00 N/A N/A N/A
Additional Field Engineering Service, 30 Days $60,000.00 $60,000.00 N/A N/A N/A

Components

Information not provided.

Cost Information

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Other Expenses

Where no predetermined cost estimate is available, any estimate provided will also become the predetermined cost (displayed in italics).
Description Predetermined
Cost Estimate
Estimated Cost Estimated Cost Justification Actual Cost Actual Cost Justification
Sub-total $135,700.00 $135,450.00 N/A $0.00 N/A
Total for all systems $3,756,905.00 $3,835,650.00 N/A $0.00 N/A
Other Expenses $135,700.00 $135,450.00 $0.00
Non-zoning permits $15,450.00 $15,450.00 $5,450 for American Tower (tower owner) and $10,000 estimated for building modifications. N/A N/A
Disposal Costs (for equipment and other waste, net of any salvage value) $25,000.00 $25,000.00 N/A N/A N/A
Required Progress Reports $5,000.00 $5,000.00 Prepare and assist with FCC-required quarterly progress reports on FCC Form 387. N/A N/A
MVPD Notification of Channel Change $2,000.00 $2,000.00 N/A N/A N/A
Develop and air announcement of upcoming channel change $10,000.00 $10,000.00 N/A N/A N/A
Equipment Delivery and Handling Charges $25,000.00 $25,000.00 N/A N/A N/A
Local Zoning $7,000.00 $7,000.00 N/A N/A N/A
Equipment Storage $25,000.00 $25,000.00 N/A N/A N/A
DTV Medical Facility Notification $11,250.00 $11,000.00 N/A N/A N/A
Additional Legal Fees $10,000.00 $10,000.00 Additional legal fees for advise and consultation regarding repack at multiple tenant site for University public TV licensee. N/A N/A

Components

Information not provided.

Cost Information

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Grand Total

Predetermined
Cost Estimate
Estimated Cost Actual Cost
Total for all systems $3,756,905.00 $3,835,650.00 $0.00

Construction Status

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Question Response
Is construction complete? No

Certification

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Section Question Response
Submission of Estimated Expenses Statements

WILLFUL FALSE STATEMENTS ON THIS FORM ARE PUNISHABLE BY FINE AND/OR IMPRISONMENT (U.S. CODE, TITLE 18, SECTION 1001), AND/OR REVOCATION OF ANY STATION LICENSE OR CONSTRUCTION PERMIT (U.S. CODE, TITLE 47, SECTION 312(a)(1), AND/OR FORFEITURE (U.S. CODE, TITLE 47, SECTION 503), AND ANY FALSE STATEMENTS COULD SUBJECT THIS ENTITY TO LIABILITY UNDER THE FALSE CLAIMS ACT.

  1. The Authorized Person signing below certifies that he/she is authorized to submit this TV Broadcaster Relocation Fund Reimbursement Form on behalf of the above-named entity.

  2. The above-named entity acknowledges that all certifications and attached documentation are considered material representations.

  3. The above-named entity acknowledges the submission of the information herein creates no obligation on the part of the government to pay any amount.

  4. The above-named entity certifies that the equipment and services paid for with money from the TV Broadcaster Relocation Fund are necessary to change channels (broadcasters) or to continue to carry the signal of a broadcaster that changes channels (MVPD).

  5. The above-named entity certifies that all payments from the TV Broadcaster Relocation Fund (Fund) received by the entity listed on this form will be used only for expenses that are eligible for reimbursement from the Fund.

  6. The above-named entity certifies that it will maintain and provide to the Commission detailed records, including receipts, of all costs eligible for reimbursement actually incurred.

  7. The above-named entity acknowledges that overpayments or payments in error must be promptly refunded to the Commission.

  8. The above-named entity certifies that it is in full compliance with all statutes, rules, regulations and governmental requirements for which compliance is a pre-requisite for obtaining the payments herein requested.

I declare, under penalty of perjury, that I am an authorized representative of the above-named applicant for the Authorization(s) specified above.

Charles Edward Meadows

President


09/14/2017

Attachments

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